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L. Patrone and H. Zayed
More recently, peripheral artery angioplasty with adjunctive orbital atherectomy
has been demonstrated to be safe and associated with low major amputation rates after
3 years of follow-up [35]. Despite some encouraging studies, strong evidence of
proper benets correlated to vessel preparation using atherectomy is still lacking [36].
Complications
Complications following endovascular intervention include access-site haemorrhage, major medical complications and distal thromboembolism or vessel occlusion. Accurate assessment of true complication rates is hampered by varying
denitions of what constitutes a major or minor complication. Moreover, the ongoing improvement in angioplasty techniques, means conclusions about current
outcomes cannot always be obtained from older literature.
The rate of major medical complication (stroke, myocardial infarction and renal
failure) is low and has been reported between 1.8 [37] and 2.4% [38]. Access vessel
complications include pseudoaneurysm, arteriovenous stula formation and accessvessel dissection or occlusion. A study by Dick etal. reported an access-site complication rate of 4.9% [37].
Access-site pseudoaneurysms can often be treated with either ultrasound-guided
compression or thrombin injection. On-going access-site haemorrhage usually
requires surgical repair. A 2002 study by Axisa etal. showed that emergency surgical intervention was required in 2.3% of cases, with the commonest aetiologies
being haemorrhagic complications and acute limb ischaemia [38]. Retroperitoneal
bleeding may be amenable to endovascular treatment with stent placement.
Distal vessel occlusion can occur as a result of ow limiting dissection or a
thromboembolic event. Flow-limiting dissection can usually be treated with prolonged balloon ination or stent placement. Occlusion due to thromboembolism can
be treated with either aspiration thrombectomy or thrombolysis. Some cases may
require surgical embolectomy.
Post-procedure Care
Immediate post-operative care comprises access site care to ensure haemostasis;
this can be achieved with manual compression (usually 10min in duration) followed by a period of bed rest and observation. Various closure devices are available
which reduce time to achieve haemostasis and allow earlier ambulation. Closure
devices are usually reserved for larger sheath sizes, with manual compression used
for 4F systems. Closure devices are particularly useful in non-compliant patients
who will be unable to lie still and at.
Stents should undergo regular duplex surveillance to identify in-stent restenosis
and enable re-intervention before occlusion occurs.
8 Endovascular Revascularisations: When andHow
97
No Option Patients
A real challenge to the endovascular clinician, is the subgroup of patients who have
non-reconstructable lower limb disease, commonly due to the absence of a distal
target vessel. The incidence of major amputation in these patients is high.
In recent years, the concept of venous arterialisation has been revisited. First
described by Halstead and Vaughan in 1912, this technique aims at diverting arterial
blood in the venous circulation in an attempt to enhance tissue perfusion in critically
ischaemic tissue. In 2016, the rst dedicated endovascular system; Limow© was
granted the CE mark, and recently, its 1-year early feasibility results showed a 70%
amputation-free survival rate using this technique [39].
On the other hand, pedal artery recanalization, and restoration of an intact pedal
arch is regarded by many as essential for optimal distal wound healing. This, however, can involve a variety of advanced endovascular techniques; e.g. Subintimal
Arterial Flossing with Antegrade and Retrograde Intervention (SAFARI), and the
evidence to support its role in enhancing amputation-free survival is still unclear.
Summary
Diabetic vascular disease commonly affects the tibial arteries and careful assessment, and planning is required before any endovascular intervention. Medical therapy should be optimised before intervention. A number of endovascular techniques
are available and should be used depending on the location and nature of the diseased arterial segment.
Key Points
• In people with diabetes arterial disease is diffuse but with particularly severe
disease with long occlusions in the tibial arteries.
• Before intervention medical therapy should be optimised.
• Patient should be able to lie at for duration of treatment.
• Inow should be restored before considering any distal intervention.
• Pre-intervention planning should consider occlusion versus stenosis, length of
diseased segment, condition and diameter of proximal and distal vessels, severity
of calcication, location of important side branches and distance from
access point.
• Ultrasound guidance should be used for atrial access.
• Drug eluting technologies have been shown to reduce brointimal hyperplasia.
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L. Patrone and H. Zayed
References
1. King P, Peacock I, Donnelly R. The UK prospective diabetes study (UKPDS): clinical and
therapeutic implications for type 2 diabetes. Br J Clin Pharmacol. 1999;48(5):643–8.
2. Graziani L, Silvestro A, Bertone V, Manara E, Andreini R, Sigala A, Mingardi R, De Giglio
R. Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic
categorization of disease severity. Eur J Vasc Endovasc Surg. 2007;33(4):453–60.
3. Mills JL Sr, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, Andros
G, Society for Vascular Surgery Lower Extremity Guidelines Committee. The Society for
Vascular Surgery Lower Extremity Threatened Limb Classication System: risk stratication
based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014;59(1):220–34.e1–2.
4. Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco J, Suresh KR,
Murad MH, GVG Writing Group. Global vascular guidelines on the management of chronic
limb-threatening ischemia. J Vasc Surg. 2019;69(6S):3S–125S.
5. Dotter CT, Judkins MP.Transluminal treatment if arteriosclerotic obstruction. Description of a
new technic and a preliminary report of its application. Circulation. 1964;30:654–70.
6. Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, Fowkes FG, Gillepsie
I, Ruckley CV, Raab G, Storkey H, BASIL trial participants. Bypass versus angioplasty in
severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet.
2005;366(9501):1925–34.
7. Dayama A, Tsilimparis N, Kolakowski S, Matolo NM, Humphries MD.Clinical outcomes of
bypass-rst versus endovascular-rst strategy in patients with chronic limb-threatening ischemia due to infrageniculate arterial disease. J Vasc Surg. 2019;69(1):156–163.e1.
8. Patel SD, Biasi L, Paraskevopoulos I, Silickas J, Lea T, Diamantopoulos A, Katsanos K, Zayed
H.Comparison of angioplasty and bypass surgery for critical limb ischaemia in patients with
infrapopliteal peripheral artery disease. Br J Surg. 2016;103(13):1815–22.
9. Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S,
Reekers J, Venermo M, Zierler RE, Hinchliffe RJ, Schaper NC.Effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic
review. Diabetes Metab Res Rev. 2020;36(Suppl 1):e3279.
10. Dilaver N, Twine CP, Bosanquet DC.Direct vs. indirect angiosomal revascularisation of infrapopliteal arteries, an updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg.
2018;56(6):834–48.
11. Darling JD, McCallum JC, Soden PA, Hon JJ, Guzman RJ, Wyers MC, Verhagen HJ,
Schermerhorn ML.Clinical results of single-vessel versus multiple-vessel infrapopliteal intervention. J Vasc Surg. 2016;64(6):1675–81.
12. Iida O, Takahara M, Soga Y, Yamauchi Y, Hirano K, Tazaki J, Yamaoka T, Suematsu N, Suzuki
K, Shintani Y, Miyashita Y, Uematsu M.Impact of angiosome-oriented revascularization on
clinical outcomes in critical limb ischemia patients without concurrent wound infection and
diabetes. J Endovasc Ther. 2014;21(5):607–15.
13. Bolia A, Miles KA, Brennan J, Bell PRF.Percutaneous transluminal angioplasty of occlusions
of the femoral and popliteal arteries by subintimal dissection. Cardiovasc Intervent Radiol.
1990;13(6):357–63.
14. Tepe G, Brodmann M, Werner M, Bachinsky W, Holden A, Zeller T, Mangalmurti S, NolteErnsting C, Bertolet B, Scheinert D, Gray WA, Disrupt PAD III Investigators. Intravascular
lithotripsy for peripheral artery calcication: 30-day outcomes from the randomized Disrupt
PAD III trial. JACC Cardiovasc Interv. 2021;14(12):1352–61.
15. Goode SD, Cleveland TJ, Gaines PA, STAG trial collaborators. Randomized clinical trial of
stents versus angioplasty for the treatment of iliac artery occlusions (STAG trial). Br J Surg.
2013;100(9):1148–53.
16. Mwipatayi BP, Sharma S, Daneshmand A, Thomas SD, Vijayan V, Altaf N, Garbowski M,
Jackson M, COBEST co-investigators. Durability of the balloon-expandable covered versus
bare-metal stents in the Covered versus Balloon Expandable Stent Trial (COBEST) for the
treatment of aortoiliac occlusive disease. J Vasc Surg. 2016;64(1):83–94.e1.
8 Endovascular Revascularisations: When andHow
17. Laird JR, Katzen BT, Scheinert D, Lammer J, Carpenter J, Buchbinder M, Dave R, Ansel G,
Lansky A, Cristea E, Collins TJ, Goldstein J, Jaff MR, RESILIENT Investigators. Nitinol
stent implantation versus balloon angioplasty for lesions in the supercial femoral artery and
proximal popliteal artery: twelve-month results from the RESILIENT randomized trial. Circ
Cardiovasc Interv. 2010;3(3):267–76.
18. Montero-Baker M, Ziomek GJ, Leon L, Gonzales A, Dieter RS, Gadd CL, Pacanowski JP Jr.
Analysis of endovascular therapy for femoropopliteal disease with the Supera stent. J Vasc
Surg. 2016;64(4):1002–8.
19. Saratzis A, Rudarakanchana N, Patel S, Diamantopoulos A, Lea T, Corbo B, Gradinariu G,
Katsanos K, Zayed H.Interwoven nitinol stents versus drug eluting stents in the femoro- popliteal
segment: a propensity matched analysis. Eur J Vasc Endovasc Surg. 2019;58(5):719–27.
20. Katsanos K, Al-Lamki SAM, Parthipun A, Spiliopoulos S, Patel SD, Paraskevopoulos I,
Zayed H, Diamantopoulos A.Peripheral stent thrombosis leading to acute limb ischemia and
major amputation: incidence and risk factors in the aortoiliac and femoropopliteal arteries.
Cardiovasc Intervent Radiol. 2017;40(3):351–9.
21. Geraghty PJ, Mewissen MW, Jaff MR, Ansel GM, VIBRANT Investigators. Three-year results
of the VIBRANT trial of VIABAHN endoprosthesis versus bare nitinol stent implantation
for complex supercial femoral artery occlusive disease. J Vasc Surg. 2013;58(2):386–95.e4.
22. Hsu CC-T, Nc Kwan G, Singh D, Rophael JA, Anthony C, van Driel ML.Angioplasty versus
stenting for infrapopliteal arterial lesions in chronic limb-threatening ischaemia. Cochrane
Database Syst Rev. 2018;12(12):CD009195.
23. Dake MD, Ansel GM, Jaff MR, Ohki T, Saxon RR, Smouse HB, Snyder SA, O’Leary EE,
Tepe G, Scheinert D, Zeller T, Zilver PTX Investigators. Sustained safety and effectiveness
of paclitaxel-eluting stents for femoropopliteal lesions: 2-year follow-up from the Zilver PTX
randomized and single-arm clinical studies. J Am Coll Cardiol. 2013;61(24):2417–27.
24. Scheinert D, Duda S, Zeller T, Krankenberg H, Ricke J, Bosiers M, Tepe G, Naisbitt S,
Roseneld K.The LEVANT I (Lutonix paclitaxel-coated balloon for the prevention of femoropopliteal restenosis) trial for femoropopliteal revascularization: rst-in-human randomized
trial of low-dose drug-coated balloon versus uncoated balloon angioplasty. JACC Cardiovasc
Interv. 2014;7(1):10–9.
25. Werk M, Langner S, Reinkensmeier B, Boettcher H, Tepe G, Dietz U, Hosten N, Hamm
B, Speck U, Ricke J. Inhibition of restenosis in femoropopliteal arteries: paclitaxelcoated versus uncoated balloon: femoral paclitaxel randomized pilot trial. Circulation.
2008;118(13):1358–65.
26. Zeller T, Brechtel K, Meyer D-R, Noory E, Beschorner U, Albrecht T. Six-month outcomes
from the rst-in-human, single-arm SELUTION sustained-Limus-release drug-eluting balloon
trial in femoropopliteal lesions. J Endovasc Ther. 2020;27(5):683–90.
27. Schmidt A, Piorkowski M, Werner M, Ulrich M, Bausback Y, Bräunlich S, Ick H, Schuster
J, Botsios S, Kruse H, Varcoe RL, Scheinert D. First experience with drug-eluting balloons in infrapopliteal arteries: restenosis rate and clinical outcome. J Am Coll Cardiol.
2011;58(11):1105–9.
28. Liistro F, Porto I, Angioli P, Grotti S, Ricci L, Ducci K, Falsini G, Ventoruzzo G, Turini F,
Bellandi G, Bolognese L.Drug-eluting balloon in peripheral intervention for below the knee
angioplasty evaluation (DEBATE-BTK): a randomized trial in diabetic patients with critical
limb ischemia. Circulation. 2013;128(6):615–21.
29. Antoniou GA, Chalmers N, Kanesalingham K, Antoniou SA, Schiro A, Serracino-Inglott F,
Smyth JV, Murray D.Meta-analysis of outcomes of endovascular treatment of infrapopliteal
occlusive disease with drug-eluting stents. J Endovasc Ther. 2013;20(2):131–44.
30. Katsanos K, Spiliopoulos S, Kitrou P, Krokidis M, Karnabatidis D. Risk of death following
application of paclitaxel-coated balloons and stents in the femoropopliteal artery of the leg:
a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc.
2018;7(24):e011245.
31. Saratzis A, Lea T, Yap T, Batchelder A, Thomson B, Saha P, Diamantopoulos A, Nikos S,
Nikos D, Zayed H.Paclitaxel and mortality following peripheral angioplasty: an adjusted and
case matched multicentre analysis. Eur J Vasc Endovasc Surg. 2020;60(2):220–9.
99
100
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
32. Rocha-Singh KJ, Duval S, Jaff MR, Schneider PA, Ansel GM, Lyden SP, Mullin CM,
Ioannidis JPA, Misra S, Tzafriri AR, Edelman ER, Granada JF, White CJ, Beckman JA, VIVA
Physicians, Inc. Mortality and paclitaxel-coated devices: an individual patient data metaanalysis. Circulation. 2020;141(23):1859–69.
33. Zeller T, Langhoff R, Rocha-Singh KJ, Jaff MR, Blessing E, Amann-Vesti B, Krzanowski M,
Peeters P, Scheinert D, Torsello G, Sixt S, Tepe G, DEFINITIVE AR Investigators. Directional
atherectomy followed by a paclitaxel-coated balloon to inhibit restenosis and maintain vessel patency: twelve-month results of the DEFINITIVE AR study. Circ Cardiovasc Interv.
2017;10(9):e004848.
34. McKinsey JF, Zeller T, Rocha-Singh KJ, Jaff MR, Garcia LA, DEFINITIVE LE Investigators.
Lower extremity revascularization using directional atherectomy: 12-month prospective
results of the DEFINITIVE LE study. JACC Cardiovasc Interv. 2014;7(8):923–33.
35. Giannopoulos S, Secemsky EA, Mustapha JA, Adams G, Beasley RE, Pliagas G, Armstrong
EJ.Three-year outcomes of orbital atherectomy for the endovascular treatment of infrainguinal claudication or chronic limb-threatening ischemia. J Endovasc Ther. 2020;27(5):714–25.
36. Abdullah O, Omran J, Al-Dadah AS, Aggarwal K, Enezate T. Atherectomy-assisted versus
percutaneous angioplasty interventions for treatment of symptomatic infra-inguinal peripheral
arterial disease. Arch Med Sci Atheroscler Dis. 2019;4:e231–42.
37. Dick P, Barth B, Mlekusch W, Sabeti S, Amighi J, Schlager O, Koppensteiner R, Minar E,
Schillinger M. Complications after peripheral vascular interventions in octogenarians. J
Endovasc Ther. 2008;15(4):383–9.
38. Axisa B, Fishwick G, Bolia A, Thompson MM, London NJM, Bell PRF, Naylor
AR.Complications following peripheral angioplasty. Ann R Coll Surg Engl. 2002;84(1):39–42.
39. Clair DG, Mustapha JA, Shishehbor MH, Schneider PA, Henao S, Bernardo NN, Deaton
DH.PROMISE I: early feasibility study of the LimFlow system for percutaneous deep vein
arterialization in no-option chronic limb-threatening ischemia: 12-month results. J Vasc Surg.
2021;74(5):1626–35.
L. Patrone and H. Zayed
Suggested Reading
Song P, Rudan D, Zhu Y, Fowkes FJI, Rahimi K, Fowkes FGR, Rudan I. Global, regional, and
national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic
review and analysis. Lancet Glob Health. 2019;7(8):e1020–30.
Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, Uccioli L, Urbancic V,
Bakker K, Holstein P, Jirkovska A, Piaggesi A, Ragnarson-Tennvall G, Reike H, Spraul M, Van
Acker K, Van Baal J, Van Merode F, Ferreira I, Huijberts M.Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without
peripheral arterial disease. The EURODIALE study. Diabetologia. 2008;51(5):747–55.
Humphries MD, Brunson A, Li C-S, Melnikow J, Romano PS.Amputation trends for patients with
lower extremity ulcers due to diabetes and peripheral artery disease using statewide data. J Vasc
Surg. 2016;64(6):1747–55.
Rashid H, Slim H, Zayed H, Huang DY, Wilkins CJ, Evans DR, Sidhu PS, Edmonds M.The impact
of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and
infrapopliteal bypass outcome. J Vasc Surg. 2013;57(5):1219–26.
Chapter 9
Surgical Revascularisation oftheDiabetic
Foot
PaulMoxey andPatrickChong
Background
Peripheral arterial disease (PAD)) affects 50% of patients presenting with a diabetic
foot ulcer. If PAD is left untreated, non-healing wounds will occur and in many
cases will deteriorate threatening both the patient’s limb and their life. PAD gives
rise to stenoses or occlusions of the lower limb arteries by the accumulation of atherosclerotic plaques within the vessel lumen preventing optimal perfusion of the
affected limb. Procedures to either bypass or re-open the diseased arterial segment
are termed revascularisation and can take the form of either endovascular radiological guided intervention (angioplasty or stenting) or open surgical bypass. To date, a
few landmark randomised trials have compared the outcomes of open versus endovascular treatment for critical limb ischaemia. The BASIL study concluded that if a
patient had more than a 2-year life expectancy and extensive tissue loss they should
be offered surgical revascularisation in the rst instance [1]. However, BASIL was
not performed exclusively in patients with diabetes and the last patient was randomised 10years ago in 2004. In that time exciting endovascular techniques have
evolved with drug eluting balloons and drug eluting stents promising to overcome
the problem of early re-stenosis in the tibial vessels following intervention in
P. Moxey
St. George’s Vascular Institute, St. George’s University Hospitals NHS Foundation Trust,
London, UK
e-mail: paul.moxey@nhs.net
P. Chong (*)
Multidisciplinary Diabetic Limb Salvage Clinic, The Surrey Heart, Stroke and Vascular
Centre, Frimley Health NHS Foundation Trust, Surrey, UK
e-mail: patrickchong@nhs.net
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
C. P. Shearman, P. Chong (eds.), Management of Diabetic Foot Complications,
https://doi.org/10.1007/978-3-031-05832-5_9
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diabetic patients. However, despite advances in endovascular techniques and technologies, the BEST-CLI study has underscored the superiority of surgical bypass
over endovascular therapy in the setting of chronic limb threatening ischaemia
(CLTI) when a patient has a suitable venous conduit for bypass [2, 9]. Results demonstrate that surgical bypass patients have less major adverse limb events (MALE),
deaths and re-interventions compared to endovascular therapy. Even in the setting
of patients without a suitable venous conduit, non-venous surgical bypass had similar outcomes to endovascular therapy. It is vital therefore for clinicians or vascular
teams looking after diabetic patients with foot tissue loss and CLTI to be procient
in providing both treatment modalities and to develop evidence based treatment
algorithms that take into account patient tness or frailty, the availability of suitable
venous conduit and the anatomical features of the peripheral arterial disease that
may render endovascular therapy technically challenging with increased kit costs
but limited clinical durability. The most recent BASIL-2 trial, a smaller scale randomised controlled study compared to the BEST-CLI trial reported better outcomes
for major amputation, all-cause mortality and amputation free survival in favour of
an endovascular therapy rst strategy over bypass surgery. 30-day mortality rates
were high for both bypass surgery (6%) and for endovascular therapy (3%) underlining the need for careful medical pre-optimisation and patient selection [3].
P. Moxey and P. Chong
Introduction
Goals ofRevascularisation
The main goal of revascularisation in the diabetic foot patient is to help the patient
achieve successful limb salvage with restored limb function and patient quality of
life. Revascularisation in the diabetic foot with ischaemia and tissue loss should be
carried out as soon as possible as further delays may lead to irretrievable tissue loss
and major amputation.
Indications forRevascularisation
The main indication for revascularisation in the diabetic foot patient is critical limb
ischaemia causing rest pain and tissue loss with either non-healing wounds or gangrene. It is important to appreciate that the presence of peripheral neuropathy may
cause some patients to present late to the multidisciplinary diabetic team because of
a lack of pain symptoms despite advanced tissue loss in the foot. In some emergency
patients with severe foot sepsis and extensive tissue loss, it may be expedient to
debride and drain the foot even before any attempt at investigation or treatment for
any underlying arterial disease. Delays may lead to irreversible foot tissue loss and
9 Surgical Revascularisation oftheDiabetic Foot
consequent major amputation. Analysis of UK Hospital Episode Statistics data
revealed that more than half of patients that underwent major lower limb amputation
between 2003 and 2008 had no attempt at revascularisation prior to losing their
limb [4].
103
Diagnosis ofPAD
The diagnosis of peripheral arterial disease (PAD) can be conrmed clinically by
bedside examination of the patient’s lower limb arterial pulses and also with the use
of non-invasive modalities in the vascular lab and imaging of the arterial blood supply to the limb.
Non-invasive Techniques intheVascular Lab
Ankle brachial pressure index (ABPI) recordings are performed with the aid of a
hand-held Doppler probe or with automated ABPI recording systems. A reduced
ABPI value of less than 0.9 suggests the presence of Peripheral Arterial Disease
(PAD) . ABPI recordings are often falsely elevated in diabetic patients due to medial
sclerosis of the ankle arteries rendering them incompressible. This is the reason why
automated ABPI recording systems are not recommended in the assessment of diabetic patients with PAD and even manual ABPI recordings can be inaccurate.
However, the audible waveforms obtained with a hand-held Doppler can be helpful
and an incompressible monophasic waveform character suggests the presence of
signicant PAD.Toe pressures are more accurate than ABPI values in the setting of
elevated ankle pressures but often outside of research settings toe pressures recordings are difcult to obtain as expertise is not available. Absolute ankle systolic pressures of less than 50mmHg or toe systolic pressures of less than 30mmHg suggest
the presence of critical ischaemia which may lead to potential limb loss unless
revascularisation takes place.
An alternative non-invasive option for the assessment of lower limb perfusion
is transcutaneous oximetry (TCpO2). TCpO2 measurement is not universally
accepted due to a perceived variability in obtaining accurate TCpO2 values which
may be affected by limb and ambient temperatures. Generally, a TCpO2 value of
less than 35mmHg suggests the presence of signicant PAD and can be a helpful
adjunct in the decision-making process when there is a need to optimise major
amputation levels or in deciding whether conservative wound management in less
t patients with tissue loss is likely to succeed. Low TCpO2 values of less than
35mmHg should prompt further investigation of the limb for PAD with vascular
imaging.
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P. Moxey and P. Chong
Vascular Imaging Options
Diabetes produces a typical pattern of multilevel disease that is particularly
aggressive below the knee in the tibial arteries. This presents a challenge for
angiography as the below knee vessels and pedal arch in particular are difcult to
clearly image on all but invasive catheter angiography. Imaging of the arterial
blood supply to the limb prior to any intervention for revascularisation is required
in order to establish the anatomical distribution of PAD in the affected limb and
to ensure that there is an adequate inow vessel proximally and target outow or
run off vessel distally to aid the long-term durability of any endovascular or open
surgical bypass technique. Vascular imaging techniques can be non-invasive or
invasive. Computer Tomography Angiography (CTA), Magnetic Resonance
Angiography (MRA), duplex ultrasound and digital subtraction angiography
(DSA) are the methods available.
Non-invasive Vascular Imaging
Duplex Scan
The simplest approach to vascular imaging is duplex scanning in the Vascular Lab.
This quick, non-invasive technique for the assessment of the lower limb arterial
blood supply is safe and acceptable to most patients. It provides both anatomical
and haemodynamic information regarding the severity of PAD in the affected limb
and its suitability for endoluminal treatment. However duplex scanning is an operator dependant technique that can be limited by bowel gas when evaluating the suprainguinal aorto-iliac segment and also by calcication present in the infra-geniculate
tibial arteries. It can also be used for vein mapping prior to a surgical reconstruction
to assess for venous conduit suitability for bypass and used for the surveillance of
existing vein bypass grafts in patients who have had previous surgery for PAD.The
added advantage of duplex scanning is that it allows the avoidance of contrast agents
in patients with renal function impairment.
Computer Tomography Angiography (CTA)
CTA allows accurate assessment of the lower limb arterial supply from the thoracic
aorta down to the level of the ankle vessels but often visualisation of the distal foot
arteries is not clear. It is also preferred when there is concomitant aneurysmal disease suspected in the aorta and the lower limb peripheral arterial system. The degree
of calcication of the aorta and peripheral arteries is also noted on CTA.CTA is the
preferred vascular imaging modality in patients with end stage renal failure or
9 Surgical Revascularisation oftheDiabetic Foot
chronic kidney disease (CKD) as gadolinium contrast used in Magnetic Resonance
Angiography (MRA) can potentially cause contrast induced nephropathy (CIN) and
in rare cases nephrogenic systemic brosis. Patients with an eGFR <30 mL/
min/1.73m2 will require prior intravenous normal saline infusions before and after
the CTA to prevent CIN.
105
Magnetic Resonance Angiography (MRA)
MRA is a useful non-invasive technique for arterial imaging of the lower limb. It
provides useful imaging of the distal tibial arteries and is easier to interpret compared to CTA especially in severely calcied arteries. MRA requires Gadolinium
contrast and may not be suitable for patients with chronic kidney disease (CKD)
and renal function impairment who are susceptible to contrast induced nephropathy (CIN). MRA is also contraindicated in patients with cardiac pacemakers,
implantable cardioverter debrillator (ICD) devices and metallic implants such as
cerebral aneurysm clips and cardiac metallic heart valves. A small proportion of
patients are also MRI intolerant due to claustrophobia. It is important to appreciate
that turbulent blood ow within diseased or stented arteries may sometimes cause
a loss of signal and thus an overestimation of disease severity when using MRA
imaging.
Invasive Vascular Imaging
Digital Subtraction Angiography (DSA)
Pragmatically the mode of imaging used is often dictated by local availability and
expertise but in our opinion a DSA is essential to planning successful bypass surgery in diabetic patients. DSA remains the gold standard in pre-operative vascular
imaging and provides accurate information about the tibial arteries even the pedal
arch in the foot. Due to the availability of non-invasive imaging, a DSA is usually
performed in conjunction with concomitant endoluminal intervention or if the anatomy or disease severity of the best arterial target vessel for intervention remains
unclear after CTA or MRA. DSA is contrast mediated and diabetic patients with
CKD and renal impairment will require prior intravenous normal saline infusion
before and after the DSA in order to avoid CIN.Access for angiography is often
obtained via a 4F sheath through the common femoral artery in the patient’s groin.
There is a small risk of complications such as bleeding or false aneurysm formation
at the site of access. DSA allows accurate assessment of the deep plantar arch vessels and identication of the best artery in communication with this arch across the
ankle joint.
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